Lab Soft News

Preventive Medicine Emerging as a New Clinical Practice Opportunity

I have posted a number of previous notes about preventive medicine and also commented about how most physicians tend to focus on the treatment of disease (disease model) rather than health promotion and preventive medicine. Below is an excerpt from an article which suggests that healthcare personnel should place more emphasis on "health" (see: Making health care about health):

As a young cardiologist, Steve Devries noticed a disturbing pattern: His patched-up heart patients kept returning for repairs. It happened so often that Devries decided there must be another way to advance patients' health. Today, his thriving Chicago practice focuses exclusively on preventing disease, and Devries is far more likely to counsel patients about diet, sleep habits and exercise than to prescribe high-tech scans or cholesterol-lowering drugs. Motivated by a growing sense that America's health care system is broken, doctors such as Devries and public health experts are turning to preventive medicine for a potential fix. And lawmakers, eager to curb rising health care costs, are paying close attention. Every serious proposal for health reform includes measures to promote healthier lifestyles and minimize the burden of disease.... Extensive research documents the potential impact. In an April article in PLoS Medicine..., researchers estimated that 191,000 fewer deaths would occur each year in the U.S. if people got more physical activity; 216,000 deaths forestalled if people were a normal weight instead of overweight or obese; and 467,000 deaths averted if people gave up smoking....A recent report in the Archives of Internal Medicine underscores the point by finding that people who live in "healthy" neighborhoods -- areas with plentiful opportunities for physical activity and eating well -- had a 38 percent lower rate of Type 2 diabetes than those in "unhealthy" neighborhoods.

I am very enthused about the idea of increasing the number of physicians specializing exclusively in preventive medicine. I hope that health insurance companies jump on this trend and provide some sort of physician and consumer incentives to enhance the status of preventive medicine. I suspect that the patients who patronize these specialists will fall into two groups: those who already are health and fitness converts and want to pursue even higher level goals and those who have had some health health problem, or even catastrophe, and need help in digging themselves out. As to the "healthy" neighborhoods described above, my guess is that they are populated by individuals with more education who are already predisposed to healthy living. Education has been shown to be the most powerful predictors of good health (see: Education Level A Leading Factor In Good Health, Longevity, According To Health Economists). Researchers have discovered that the correlation between health and education goes beyond a pure understadnding of health maintenance. It may, in fact, have something to do with investing in oneself for the future.

Reaction to Note on Flaws in the Canadian Healthcare Delivery System

In a recent note, I discussed some flaws in the Canadian healthcare delivery system and how it possibly could be reformed (see: The Fundamental Flaws in the Canadian Healthcare Delivery System), quoting the work of Nadeem Esmail, an economist from the Fraser Institute. The piece has stimulated two Canadian physician readers to submit comments, which I now elevate to the level of this note:

• (Dr. EM) [Nadeem Esmail] removed data from some OECD slides to enhance his point: the country with the largest %GDP health spending is the USA -- by far. In 2003, USA= 16%GDP, Canada= 10%. Other than that, the overall message is correct. In particular, Canadian doctors are truly more pessimistic than other doctors, as shown here. His solution is good, rational and should be well accepted by hospital admins, doctors and patients alike. But it will not happen, because Canadian politicians handle health care (35% of all public expenditure) like a sleeping dragon: action only if absolutely necessary. Unlike Obama, we in Canada hope there's no change
• (Dr. Murray Treloar) As a Canadian doc, I can say that these comments resonate. However, it must be recognized that the Fraser Institute is a conservative (read Republican) 'think tank' and can be relied on for right-leaning analyses. What the US and Canada need is evidence based debate, not ideological ramblings. Neither system is sustainable.

I did state in my first bullet point that Nadeem had stated unequivocally during his presentation that he was only comparing those OECD countries that offer universal health coverage in his comparison slides. No one disputes the fact that the U.S. spends more per capita on healthcare as a percentage of the GDP than the U.S. I also suspect that, on average, U.S. physicians work many more hours per week than the physicians in other countries so that the hourly compensation for some may not actually be that different than their peers. For those U.S. physicians who perform procedures, I am sure that their income dwarfs that of comparable physicians in other countries.

I must admit that I did not know anything about the political orientation of the the Fraser Institute when I posted the note. I did have the distinct impression that Nadeem was not a staunch liberal because of his willingness to criticize Canada's universal health system. However, I think that it will be more productive to discuss healthcare reform from the perspective of incentives rather than political labels. Here are some examples what I consider to be major flaws in the current U.S. healthcare delivery system in terms of incentives:

• Physicians have an incentive to provide too many procedures because they are rewarded financially on this basis rather than on treatment effectiveness.
• Healthcare consumers with insurance have an incentive to consume far too many services because they do not pay out-of-pocket for them. They also have few incentives to take better care of themselves.
• Health insurance executives have an incentive to demand ever-increasing compensation, including lucrative stock options, while minimizing costs by cherry-picking customers and denying claims to existing clients on the basis of preexisting conditions.
• Health insurance executives have few incentives to simplify their billing procedures in order to lower administrative costs and, in fact, have an incentive to make them more complicated as a basis for denying claims on technicalities.
• Health system executives have an incentive to take advantage of their non-profit status by allocating only a small portion of their budgets to uncompensated care while simultaneously expanding their facilities to compete with regional competitors.
  

The Fundamental Flaws in the Canadian Healthcare Delivery System

I recently attended the Executive Edge conference in Toronto that focused on various aspects of clinical lab management in Canada. For me, one of the most impressive lectures was delivered by Nadeem Esmail, Director of Health System Performance Studies at The Fraser Institute (see: Demographics, New Technologies, and Health Care). He presented a critique of the Canadian healthcare delivery system from the perspective of an economist and healthcare analyst. Given that the U.S. is now enmeshed in a prolonged debate about how to improve our own system, I thought that it would be useful to present the key points of his analysis of a system admired by many in the U.S.:

• Canada lags behind most other countries with similar universal healthcare systems in terms of capital expenditures for expensive diagnostic and therapeutic devices such as MRI, CT, and PET scanners as well as lithotriptors (see, for example, slides 4, 6, 7, and 8).
• Canadian physicians, when polled, express the belief that their ability to deliver care has gotten worse in the past five years (slide 13). If the physicians concede this, I suspect most patients would hold the same opinion.
• Wait-times in Canada for MRI studies for 1994 to 2008 have have varied from eight to ten weeks (slide 37). I don't know the comparable figure for the U.S. as a whole but I suspect that its about one quarter to one third of that in Canada. One of the debates here is whether we have too many MRI devices with some then underutilized.
• These problems in Canada cannot be attributed to any lag in per capita spending. Slide 40 shows age-adjusted health spending as a percentage of GDP in the 28 OCED (Organization for Economic and Co-operative Development) countries. Canada ranks second from the top, next to Iceland in terms of its spending for healthcare.

Nadeem explained the essence of the Canadian healthcare problem in the following way:

• Canadian politicians at the provincial and national level, much like their colleagues south of the border, are most interested in getting re-elected. Laboratory analyzers and radiology imaging devices don't vote but nurses and other hospital employees do have this privilege. Healthcare expenditures by the government are thus primarily directed toward salary increases, particularly to workers represented by politically strong labor unions. Nadeem illustrated this fact by saying that a hospital cook in Vancouver makes more than a chef working in the finest restaurant.
• This problem is compounded by the fact that hospital executives work with what Nadeem called "soft" budgets. They generally receive the same budget allocation for their hospital as the previous year plus some modest percentage increase in good years. They thus "sit" on their resources and resist large capital expenditures that might be necessary to stay abreast of new technology. Canadian patients have little recourse but to utilize the hospitals in their neighborhood because the healthcare delivery system is a national monopoly. Of course, they can always play the "medical tourism card" if the queues are too long in Canada or they absolutely require more sophisticated imaging technology quickly.
• Nadeem favors conversion to "activity-based" healthcare funding model such as that used in Switzerland. Hospital budgets there are based on the number of patients treated during the year, which focuses the attention of hospital executives on delivering quality care and competing with other hospitals. In other words, the Swiss system tends to be more patient-centric rather than budget-centric. The federal funds to support the universal healthcare system are allocated to the health insurance companies which, in turn, favor those hospitals that provide the highest quality care.

Decision-Aids for Helping Consumers Make Informed Medical Decisions

Who is the best person to advise you on important medical decisions? Nearly everyone would respond to this question by citing their family physician. It turns out that this ain't necessarily so according to a recent article (see: Weighty Choices, in Patients’ Hands). Here are some of the details:

For patients [with serious diseases], the current health-policy debate comes down to a very personal issue: how to make ever-more-complex decisions when faced with multiple options, each with no clear advantage and with risks and harms that patients may value differently. Preliminary data from the National Survey of Medical Decisions, conducted by researchers at the University of Michigan, showed that doctors are more likely to discuss the advantages of treatments while giving short shrift to the disadvantages. The study also found that doctors often offer their opinion but much less frequently ask the patient’s own opinion....Though decision-aid programs cost money to deliver, they appear to save money in the long run. Studies show that when patients understand their choices and share in the decision-making process with their doctors, they tend to choose less-invasive and less-expensive treatments than they would have otherwise received. A number of states and policymakers in Washington are considering legislation that would provide funding to study the use of shared-decision-making programs and in some cases require such programs to be offered to patients as part of the informed-consent process. A growing number of hospitals, medical groups and health plans are using decision aids offered by the Foundation for Informed Medical Decision Making, which grew out of research at Dartmouth University, for conditions where there is no consensus as to the best course of treatment. The foundation offers decision aids for 23 diseases and conditions including breast and prostate cancer, knee surgery, end-of-life care and uterine fibroids. Health Dialog, its for-profit partner, provides the programs to health plans and employers reaching about 20 million beneficiaries. Using claims data, Health Dialog determines which patients might benefit from shared decision making, then reaches out to them by mail or phone to offer informational DVDs and telephone-coaching sessions to help make decisions.

I believe, as stated above, that physicians are more like to discuss the advantages and benefits of treatment than the disadvantages. In effect, they are trained to "sell" various treatments and therapies. After all, that is the business that they are in and all of them firmly believe in what they are "selling." Coupled with this, there is always the problem that surgeons like to operate and oncologists are trained to offer chemotherapy to nearly all of the patients who are referred to them. Some of these problems can be reduced by the use of multidisciplinary teams (MDTs) in cancer hospitals and breast clinics (see: The Value of "One-Stop" Breast Cancer Clinics Confirmed in the U.K.). One of the antidote to this problem is the well-informed patient and the web is one of the vehicles for educating healthcare consumers.

I think that it would be a bit of a stretch to suggest that all patients should make use of the "decision-aids" described above to help them navigate through complex medical decisions. The use of such products could seriously disrupt the critical patient-physician relationship. Obviously, health plans and employers, as described above, could mandate their use because they are paying the medical bills. The experience gained in these new approaches will be invaluable. Meanwhile, it would help if these "decision-aids" as well as supplemental educational materials could be made more broadly available on the web. In this way, motivated patients needing help in making significant medical decisions could have access to them in parallel with discussions with their personal physicians. Ideally, the advice obtained on the web would reinforce the same decisions arrived at in discussions with their physicians. If not and perhaps for some patients, these decision-aids could guide them in a better direction based on their individual needs.

Horizontal and Vertical Integration of Diagnostics into Healthcare Processes

Integrated diagnostics can be defined as the integration of the diagnostic activities of specialties such as pathology, lab medicine, and pathology into related healthcare processes such as therapeutics (see for example: Siemens' Pursuit of an Integrated Diagnostics Portfolio; The Evolution of Integrated Diagnostics into Integrated Diagnostic Centers). This goal is pursued in order to get beyond the "diagnostic silos" that are the norm today. By this latter term, I mean that the various diagnostic professionals work independently to generate their reports but, of course, frequently refer to the previously published reports of the other groups. The development of an integrated diagnostic center is one way to solve the silo problem (see for example: Can Existing Breast Clinics Evolve into Integrated Diagnostic Centers?). Such a center is an example of horizontal integration. This macroeconomic and business strategy term refers to ownership and control of businesses in separate parallel markets. In this example, I view the practice of radiology, pathology, and lab medicine as separate markets.

In hospital and medical office workflow, diagnostics can be viewed as being upstream of treatment in the sense that it occurs prior to treatment. Using again a business term, vertical integration involves the control by clinicians of upstream diagnostic processes.The classic example of vertical integration in today's healthcare system is cardiology. Cardiologists frequently manage and control some of the heart and vascular imaging modalities in hospitals. This specialty thus tends to function as a partly vertically integrated industry.

In previous posts, I have discussed in-office histopathology labs whereby gastroenterology and urology practice groups process and interpret histopathology slides in-house, with the pathology reports generated by pathologists who work as contractors for the group (see: Corrected Definition for a Pod Lab and a Look at In-Office Labs). I have already pointed out that these in-office labs can be considered as examples of integrated diagnostic centers (see: More on Integrated Diagnostic Centers; Trend or Lukewarm Idea?). Below is a excerpt from that note:

...a urology or gastroenterology group practice with an in-office histology lab is already functioning, to a large extent, as what I have defined as an IDC [integrated diagnostic center]. By decreasing the time to process tissue specimens and the use of telepathology or an on-site pathologist, a final surgical pathology report for a patient could potentially be generated in a small number of hours. Similarly, histopathology labs could also be "integrated" into ambulatory surgery centers (ASCs) and these latter facilities could also then function as IDCs.

There is certainly nothing wrong with vertical integration in healthcare, by which I mean integrating upstream diagnostic processes with downstream clinical processes. However, there is a quality difference between horizontal and vertical integration of diagnostics. In the former, the various diagnosticians closely collaborate, communicate, and learn from each other. I believe that this results in higher quality integrated diagnostic reports. With vertical integration, as in the case of in-office histopathology labs, the diagnostic pathology processes differs little from the previous ones in which the tissue specimens are referred to a separate and outside pathology group for processing and interpretation. Of course and in this case, the pathologist is on-site, which should result in better communication with the clinicians in the group.

Expenditures by Consumers on Complementary and Alternative Medicine

I illustrated in a previous note that there is broad overlap between wellness, pre-disease, and complementary and alternative medicine (CAM) (see: Wellness, Preventive Medicine, and the Classic Disease Model). Complementary medicine can be defined in the following way:

...[C]omplementary medicine is used by conventional medical practitioners to refer to non-invasive, non-pharmaceutical techniques which are used in conjunction with medical treatments such as drugs and surgery. The term implies that conventional medicine is used as a primary tool and the non-invasive, non-pharmaceutical techniques are used as a supplement when needed.

I fully understand that CAM is a broad term and incorporates a number of therapies that may provide few objective health gains such as aromatherapy. However, many of others in the same category such as yoga are now mainstream and provide a large number of tangible benefits. I think that it's important for lab professionals to understand the size of the CAM market and also the role that clinical lab testing may play in it. Below is an excerpt from an article about the topic (see: $33.9 Billion Spent Out-Of-Pocket On Complementary And Alternative Medicine By Americans) that may be useful in launching this dialogue:

Americans spent $33.9 billion out-of-pocket on complementary and alternative medicine (CAM) over the previous 12 months, according to a 2007 government survey. CAM is a group of diverse medical and health care systems, practices, and products such as herbal supplements, meditation, chiropractic, and acupuncture that are not generally considered to be part of conventional medicine. CAM accounts for approximately 1.5 percent of total health care expenditures ($2.2 trillion) and 11.2 percent of total out-of-pocket expenditures ....Approximately 38 percent of adults use some form of CAM for health and wellness or to treat a variety of diseases and conditions, according to data from the 2007 National Health Interview Survey....Of the $33.9 billion spent on CAM out-of-pocket, an estimated $22.0 billion was spent on self-care costs – CAM products, classes, and materials – with the majority going to the purchase of nonvitamin, nonmineral, natural products ($14.8 billion) such as fish oil, glucosamine and Echinacea. U.S. adults also spent approximately $11.9 billion on an estimated 354.2 million visits to CAM practitioners such as acupuncturists, chiropractors, massage therapists, etc. To put these figures in context, the $14.8 billion spent on nonvitamin, nonmineral, natural products is equivalent to approximately one-third of total out-of-pocket spending on prescription drugs, and the $11.9 billion spent on CAM practitioner visits is equivalent to approximately one-quarter of total out-of-pocket spending on physician visits.

The last sentence here is critical -- CAM accounts for one-third of the total out-of-pocket spending on prescription drugs and one-quarter of total out-of-pocket spending on physician visits. Can this segment of healthcare expenditures be totally ignored by "conventional" medical practitioners, including pathologists and lab professionals, for much longer? But such a statement begs the more important question. In what way can lab professionals provide service to consumers who are using CAM? Two ideas come quickly to mind. The first is the development of reliable quantative assays for the active ingredients in the most popular herbal remedies such as Echinacea. The second is to measure serum analytes and biomarkers to monitor improvements in joint and muscle functions following yoga practice or acupuncture sessions. Early attempts have also been tried to improve the symptoms of Parkinson's disease with yoga, monitored by serum levels of dopamine (see: Moving On with Parkinson's).

Some Interesting Statistics about the Continuing Growth of Ambulatory Surgery

I have concerns about the continuing migration of various diagnostic and surgical procedures to office, clinic, and ambulatory settings. My concerns are based on the fact that the majority of pathologists, and the clinical labs that they manage, are hospital-based. A large percentage of the small biopsy surgical pathology work is migrating to in-office histopathology labs where it is diagnosed by pathologists working for large clinical groups (see: Corrected Definition for a Pod Lab and a Look at In-Office Labs, More on Integrated Diagnostic Centers; Trend or Lukewarm Idea?). Ambulatory surgery centers (ASCs) are also widely proliferating, many of them physician-owned (see: Outpatient Surgery Now Dominates the Inpatient Variety in the U.S.). A recent article in the Wall Street Journal provides some current numbers to this ambulatory surgery trend (see: Seeking a Safer Surgery), Below is an excerpt from it:

...[A] growing number of states are regulating [surgical] procedures in doctors’ offices, or weighing measures to do so, including California, Indiana, Florida, Arizona and Nevada. This month, a law took effect in New York that for the first time requires the state’s approximately 3,000 doctors’ offices that perform surgery under moderate or deep sedation to have their facilities inspected and accredited by independent review agencies....Outpatient surgery, from simple skin growth removals to knee replacements, accounts for more than 65% of all surgeries, up from about 20% two decades ago. Thanks to advances in anesthesia and minimally invasive surgical techniques, outpatient surgery offers lower costs, more convenient scheduling, and faster recovery and healing times than do hospital inpatient procedures. About 45% of [outpatient surgery] take place in hospital outpatient departments, which are operated by highly regulated hospitals. An additional 38% of outpatient procedures are performed in more than 5,000 ambulatory surgery centers, which typically are certified by the federal Center for Medicare and Medicaid Services, are accredited by an independent agency, and may also have to be licensed by their state. To be accredited, facilities must meet strict standards for equipment, operating-room safety, personnel training and surgeon credentials. Doctor’s offices in states with no regulation may perform surgery solely under the medical license of the physician with no formal licensing or accreditation requirements. Some doctors choose to be voluntarily accredited by one of three agencies that perform the inspections, but the process can cost several thousand dollars.

I don't need to embellish the facts. The trend toward ambulatory surgery is obvious. In my opinion, hospital-based pathologists need to be more aggressive in pursuing collaborative ventures with the large clinical urology and gastroenterology groups and ASCs for their surgical pathology business. The momentum toward ambulatory surgery can only increase in volume in upcoming years. Given that most of oncology care is delivered on an outpatient basis, most inpatient stays will soon be confined to critical care patients, many of them trauma victims, and perhaps end-of-life care. However, many of these latter patients, hopefully, will be served in the future by hospices or by family members in a home setting.

Lecture Notes Available for Deloitte Webinar on Comparative Effectiveness

The term comparative effectiveness is much in the news these days, often in connection with discussions about healthcare reform. I have posted previous notes about it in addition to an allied concept, treatment efficacy. Comparative effectiveness, in my mind, is also a first cousin to evidence-based medicine (EBM). All of these concepts are associated with the need to treat patients in the most effective manner. They also relate to the important goal of compensating physicians for treatments that are likely to improve the health status of patients rather than on a fee-for-service basis.

A recent webinar by consultants from Deloitte on comparative effectiveness provided a very comprehensive view of the topic. Following the presentation, the firm provided a link to their PowerPoint presentation (see: Comparative Effectiveness: A Compelling Approach to Cost Control and Quality Improvement). Complimentary registration is required to view or download this file. The only "problem" with the presentation is that it is so comprehensive that it probably can't be absorbed at one sitting.

Slide #5 in the set is the healthcare reform pyramid covered here in previous blog note and which I like so much that I have used it some of my own lectures (see: A Look at Deloitte's Healthcare Reform Pyramid: A Strategy for Reducing Costs). I was also impressed with the distinction made between comparative efficacy and effectiveness in slide #11. Here is a list of the differences between the two  copied from that slide:

• Efficacy: (1) Performance under controlled or ideal conditions; (2) Question addressed: Is the intervention better than placebo or doing nothing; (3) Methods: Randomized, controlled clinical trials

• Effectiveness: (1) Performance under “real life” practice conditions; (2) Question addressed: Does this intervention achieve better health outcome in real-world situation; (3) Methods: “Real-world” clinical trials; observational studies

One of my criticisms of evidence-based medicine, covered in a previous note (see: Flaws in Evidence-Based Medicine), is its rigidity. Many of the EBM recommendations in the literature can't be applied by physicians in practice. The article quoted in this latter note calls for a more patient-centric and cost-efficient approach to patient care than EBM. The Deloitte definition for comparative efficacy and effectiveness suggests that, in the former, evidence flows from controlled clinical trials. The latter relates more to "real-world" clinical trials and observational studies. I am not sure whether comparative effectiveness research will prove to be useful in providing recommendations for physicians about the most effective treatments for their patients. My immediate concern is that the concepts of "real-world" clinical trials and observational studies will be difficult to define and may therefore be rejected by the academics who will be managing the comparative effectiveness studies and projects sponsored by the government.

A Concrete Plan for Reducing Administrative Red Tape in Healthcare

Everyone seems to be in agreement that the administrative costs in healthcare are a major burden and contribute to the rapidly increasing cost of services. A recent article on this topic concluded with a call for physician practices, hospitals, insurance payers, benefits managers and others to adopt a coordinated approach for the reduction of red tape (see: Cutting healthcare red tape could save billions, says coalition). Below is an excerpt from the article with

The nation could save billions of dollars each year in the healthcare system by addressing certain areas of administrative complexity, according to a new report from the Healthcare Administrative Simplification Coalition. HASC is a public/private partnership of organizations committed to reducing the administrative costs and complexity of healthcare. The report, "Bringing Better Value: Recommendations to Address the Costs and Causes of Administrative Complexity in the Nation's Healthcare System," estimates that reducing administrative costs by 10 percent could save as much as $500 billion over 10 years....

[The following are the key elements in a plan to reduce administrative complexity and costs:]

• Credentialing physicians and other clinicians – A universal credentialing form would eliminate hundreds of hours of repetitious paperwork that physician practices devote to completing multiple credentialing forms for insurance payers, hospitals and others.
• Determining and verifying patient eligibility for health insurance – Adoption of an industry-wide standard for interchangeable electronic data would help hospitals and physician practices determine each patient's insurance coverage more quickly and accurately.
• Standardizing healthcare patient identification cards – Standardizing the design and content of patient ID cards and ensuring they are machine-readable would significantly reduce costly errors and delays in the medical claims billing process.
• Improving coordination of prior authorization processes for radiology and pharmacy services – A voluntary, standardized approach to how providers request and receive determinations of patient eligibility for pharmacy benefits and radiology services would reduce treatment delays and reduce costly paperwork.

All of this makes so much good sense that one wonders why similar voluntary guidelines have not been adopted in the past in the field. My guess is that the health insurance system, for example, is so large, unwieldy, and fragmented that no one organization had the clout or the incentive to advocate change. Everyone, therefore, perversely accepted the status quo. We are currently in the throes of a major healthcare reform frenzy but it's not clear if anything useful will come out of it. One can only hope that one consequence of this process will be some form of standardization of administrative procedures similar to the one described above.

Mayo Clinic to Open Walk-In Clinic in Mall of America

Walk-in clinics that are located in malls, big-box stores, and retail drug stores have provided a new model for healthcare delivery at the basic level. They are frequently staffed by nurse clinicians and provide only a limited array of services. Patients with serious or acute problems are referred to other facilities. Generally speaking, these clinics have not offered lab testing in keeping with the type of low-level problems being treated. Although most of these clinics have been launched by for-profit companies, other health systems such as the Cleveland Clinic have opted to participate in the new model (see: Cleveland Clinic Partners with Minute Clinic in Retail Health Services). A recent article discussed how Mayo was planning to open a clinic in the Mall of America with a somewhat different mission, marking perhaps a new strategy for some of these operations (see: Mayo Clinic going to Mall of America). Below is an excerpt from the article:

In a move that could shake up the Twin Cities health care market, Mayo Clinic said Wednesday that it plans an outpost amid the roller coasters, restaurants and retailers as the Mall of America expands into a second phase. Mayo officials said they haven't decided what services the site will offer, but said they could include diagnostic screenings, wellness counseling and other services that might direct patients to the home campus in Rochester....The new facility might, for example, offer telemedicine consultations and organize logistics for international patients. But it will not offer routine primary care such as treating sore throats and broken bones. At a news conference on Wednesday attended by Mall officials and Gov. Tim Pawlenty, Mayo executives said they plan to spend the next 12 months deciding the nature of the facility and the size of their investment. There is no opening date as yet.

There has been extensive tinkering with the walk-in retail clinic business model lately, including some versions that are offering an expanded menu of services to attract more patients (see: A New Version of the Walk-In Retail Health Clinic Launches in Walgreens). One logical extension of walk-in clinics, in my opinion, will be toward wellness, health maintenance, and predictive/preventive medicine. It's revealing that the article quoted above emphasized the following activities in the planned clinic (1) diagnostic screening; (2) wellness counseling; and (3) telemedicine consultations. Also interesting was that primary care services were ruled out for the clinic. Of course, primary care is far from the core business of Mayo.

Notice the reference in the article to organizing logistics for international patients. Both the Cleveland and Mayo Clinics cultivate this aspect of healthcare delivery. My guess is that the families of many of these patients occupy themselves with shopping when their relative is being seen in Rochester. What better location for this activity than Mall of America with a gross area of 4.2 million square feet and 520 stores. Of course, integrating shopping with healthcare will not work for every health system. Let's stay tuned to see what happens with the proposed telemedicine consultations.